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                    <h3 style="margin-left: 5px;">Best finance group of Toronto</h3>
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                        Phone 1-877-341-0593 <br />
                        FAX  1-800-494-1167
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                        <li><a href="#">Line of credit</a></li>
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                        <li><a href="#">Something else here</a></li>
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            <h2>Best Interest Capital Group: Application Form</h2>
            <hr>
            <p>We have the fastest and easiest loan process in the business! Apply anytime to get your loan approved!
                Please note that you must be at least 18 years of age and a permanent resident of Canada or The United
                States to qualify. To better serve you, please ensure that all fields are complete before clicking on
                the 'SUBMIT' button</p>
            <form class="form-horizontal">
                <hr>
            <div class="span5">
                <div class="control-group">
                    <label class="control-label">First Name</label>

                    <div class="controls">
                        <input class="span3" type="text" placeholder="First Name">
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">Address</label>

                    <div class="controls">
                        <input class="span3" type="text" placeholder="Address">
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">State/Province</label>

                    <div class="controls">
                        <select name="form[State or Province][]" id="State or Province" class="rsform-select-box">
                            <option selected="selected" value="">Please Select</option>
                            <option value="Alabama">Alabama</option>
                            <option value="Alaska">Alaska</option>
                            <option value="Arizona">Arizona</option>
                            <option value="Arkansas">Arkansas</option>
                            <option value="California">California</option>
                            <option value="Colorado">Colorado</option>
                            <option value="Connecticut">Connecticut</option>
                            <option value="Delaware">Delaware</option>
                            <option value="Florida">Florida</option>
                            <option value="Georgia">Georgia</option>
                            <option value="Hawaii">Hawaii</option>
                            <option value="Idaho">Idaho</option>
                            <option value="Illinois">Illinois</option>
                            <option value="Indiana">Indiana</option>
                            <option value="Iowa">Iowa</option>
                            <option value="Kansas">Kansas</option>
                            <option value="Kentucky">Kentucky</option>
                            <option value="Louisiana">Louisiana</option>
                            <option value="Maine">Maine</option>
                            <option value="Maryland">Maryland</option>
                            <option value="Massachusetts">Massachusetts</option>
                            <option value="Michigan">Michigan</option>
                            <option value="Minnesota">Minnesota</option>
                            <option value="Mississippi">Mississippi</option>
                            <option value="Missouri">Missouri</option>
                            <option value="Montana">Montana</option>
                            <option value="Nebraska">Nebraska</option>
                            <option value="Nevada">Nevada</option>
                            <option value="New Hampshire">New Hampshire</option>
                            <option value="New Jersey">New Jersey</option>
                            <option value="New Mexico">New Mexico</option>
                            <option value="New York">New York</option>
                            <option value="North Carolina">North Carolina</option>
                            <option value="North Dakota">North Dakota</option>
                            <option value="Ohio">Ohio</option>
                            <option value="Oklahoma">Oklahoma</option>
                            <option value="Oregon">Oregon</option>
                            <option value="Pennsylvania">Pennsylvania</option>
                            <option value="Rhode Island">Rhode Island</option>
                            <option value="South Carolina">South Carolina</option>
                            <option value="South Dakota">South Dakota</option>
                            <option value="Tennessee">Tennessee</option>
                            <option value="Texas">Texas</option>
                            <option value="Utah">Utah</option>
                            <option value="Vermont">Vermont</option>
                            <option value="Virginia">Virginia</option>
                            <option value="Washington">Washington</option>
                            <option value="West Virginia">West Virginia</option>
                            <option value="Wisconsin">Wisconsin</option>
                            <option value="Wyoming">Wyoming</option>
                            <option value="--------------------">--------------------</option>
                            <option value="Alberta">Alberta</option>
                            <option value="British Columbia">British Columbia</option>
                            <option value="Manitoba">Manitoba</option>
                            <option value="New Brunswick">New Brunswick</option>
                            <option value="Newfoundland &amp; Labrador">Newfoundland &amp; Labrador</option>
                            <option value="Northwest Territories">Northwest Territories</option>
                            <option value="Nova Scotia">Nova Scotia</option>
                            <option value="Nunavut">Nunavut</option>
                            <option value="Ontario">Ontario</option>
                            <option value="Prince Edward Island">Prince Edward Island</option>
                            <option value="Quebec">Quebec</option>
                            <option value="Saskatchewan">Saskatchewan</option>
                            <option value="Yukon">Yukon</option>
                        </select>
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">Date of birth</label>

                    <div class="controls">
                        <select name="form[month][]" id="month" class="span1">
                            <option value="Jan">Jan</option>
                            <option value="Feb">Feb</option>
                            <option value="Mar">Mar</option>
                            <option value="Apr">Apr</option>
                            <option value="May">May</option>
                            <option value="Jun">Jun</option>
                            <option value="Jul">Jul</option>
                            <option value="Aug">Aug</option>
                            <option value="Sep">Sep</option>
                            <option value="Oct">Oct</option>
                            <option value="Nov">Nov</option>
                            <option value="Dec">Dec</option>
                        </select> <select name="form[Date][]" id="Date" class="span1">
                            <option value="1">1</option>
                            <option value="2">2</option>
                            <option value="3">3</option>
                            <option value="4">4</option>
                            <option value="5">5</option>
                            <option value="6">6</option>
                            <option value="7">7</option>
                            <option value="8">8</option>
                            <option value="9">9</option>
                            <option value="10">10</option>
                            <option value="11">11</option>
                            <option value="12">12</option>
                            <option value="13">13</option>
                            <option value="14">14</option>
                            <option value="15">15</option>
                            <option value="16">16</option>
                            <option value="17">17</option>
                            <option value="18">18</option>
                            <option value="19">19</option>
                            <option value="20">20</option>
                            <option value="21">21</option>
                            <option value="22">22</option>
                            <option value="23">23</option>
                            <option value="24">24</option>
                            <option value="25">25</option>
                            <option value="26">26</option>
                            <option value="27">27</option>
                            <option value="28">28</option>
                            <option value="29">29</option>
                            <option value="30">30</option>
                            <option value="31">31</option>
                        </select>
                        <input type="text" value="" name="form[Year]" id="Year"
                                         class="span1">

                    </div>
                </div>
                <div class="control-group">
                   <label class="control-label">Phone Number</label>

                   <div class="controls">
                       <input class="span3" type="text" placeholder="Phone Number">
                   </div>
               </div>
                <div class="control-group">
                   <label class="control-label">E-mail</label>

                   <div class="controls">
                       <input class="span3" type="text" placeholder="E-mail">
                   </div>
               </div>
            </div>
            <div class="span5">
                <div class="control-group">
                    <label class="control-label">Last Name</label>

                    <div class="controls">
                        <input class="span3" type="text" placeholder="Last Name">
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">City</label>

                    <div class="controls">
                        <input class="span3" type="text" placeholder="City">
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">Zip/Postal Code</label>

                    <div class="controls">
                        <input class="span3" type="text" placeholder="Zip/Postal">
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">SSN/SIN (Optional: For quicker responses)</label>

                    <div class="controls">
                        <input class="span3" type="text" placeholder="SSN/SIN">
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">Alternate contact number</label>

                    <div class="controls">
                        <input class="span3" type="text" placeholder="Contact number">
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">Confirm Email</label>

                    <div class="controls">
                        <input class="span3" type="text" placeholder="Email">
                    </div>
                </div>
            </div>
            <div style="clear: both;"></div>
            <hr />
            <h4>Please tell us a little about your employment history</h4>
            <div class="span5">
                <div class="control-group">
                    <label class="control-label">Company Name</label>

                    <div class="controls">
                        <input class="span3" type="text" placeholder="Company Name">
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">Work Title/Occupation</label>

                    <div class="controls">
                        <input class="span3" type="text" placeholder="Work Title/Occupation">
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">Work Number</label>

                    <div class="controls">
                        <input class="span3" type="text" placeholder="Work Number">
                    </div>
                </div>
            </div>
            <div class="span5">
                <div class="control-group">
                    <label class="control-label">Employment Status</label>

                    <div class="controls">
                        <select name="form[EmploymentStatus][]" id="EmploymentStatus">
                            <option selected="selected" value="">Please Select</option>
                            <option value="Part Time">Part Time</option>
                            <option value="Full Time">Full Time</option>
                            <option value="Self Employed">Self Employed</option>
                        </select>

                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">Length of Employment</label>

                    <div class="controls">
                        <select name="form[employmentTime][]" id="employmentTime">
                            <option selected="selected" value="">Please Select</option>
                            <option value="Less than 1 year">Less than 1 year</option>
                            <option value="More than 1 year">More than 1 year</option>
                            <option value="More than 2 years">More than 2 years</option>
                            <option value="More than 3 years">More than 3 years</option>
                            <option value="More than 4 years">More than 4 years</option>
                            <option value="More than 5 years">More than 5 years</option>
                        </select>
                    </div>
                </div>
            </div>
            <div style="clear: both;"></div>
            <hr>
                <h4>Please provide us with some of your financial information</h4>

                <div class="span5">
                    <div class="control-group">
                       <label class="control-label">Housing Status</label>

                       <div class="controls">
                           <select name="form[Housing][]" id="Housing" class="rsform-select-box">
                               <option selected="selected" value="">Please Select</option>
                               <option value="Rent">Rent</option>
                               <option value="Own">Own</option>
                               <option value="Live with family/parents">Live with family/parents</option>
                               <option value="Other">Other</option>
                           </select>
                       </div>
                   </div>
                    <div class="control-group">
                        <label class="control-label">Net monthly income</label>

                        <div class="controls">
                            <input class="span3" type="text" placeholder="Net monthly income">
                        </div>
                    </div>
                    <div class="control-group">
                        <label class="control-label">Have you ever claimed bankruptcy</label>

                        <div class="controls">
                            <label style="margin-top: 15px;" for="Bankruptcy0" class="radio inline"><input name="form[Bankruptcy]" type="radio" value="Yes" id="Bankruptcy0">Yes</label>
                            <label style="margin-top: 15px;" class="radio inline" for="Bankruptcy1"><input name="form[Bankruptcy]" type="radio" value="No" id="Bankruptcy1">No</label>

                        </div>
                    </div>
                    <div class="control-group">
                       <label class="control-label">What amount are you looking to borrow?</label>

                       <div class="controls">
                           <select name="form[LoanAmount][]" id="LoanAmount" style="margin-top: 10px;">
                               <option selected="selected" value="">Please Select</option>
                               <option value="$7,500">$7,500</option>
                               <option value="$8,000">$8,000</option>
                               <option value="$8,500">$8,500</option>
                               <option value="$9,000">$9,000</option>
                               <option value="$9,500">$9,500</option>
                               <option value="$10,000">$10,000</option>
                               <option value="$15,000">$15,000</option>
                               <option value="$20,000">$20,000</option>
                               <option value="$25,000">$25,000</option>
                               <option value="$30,000">$30,000</option>
                               <option value="$35,000">$35,000</option>
                               <option value="$40,000">$40,000</option>
                               <option value="$45,000">$45,000</option>
                               <option value="$50,000">$50,000</option>
                               <option value="$60,000">$60,000</option>
                               <option value="$70,000">$70,000</option>
                               <option value="$80,000">$80,000</option>
                               <option value="$90,000">$90,000</option>
                               <option value="$100,000">$100,000</option>
                               <option value="$125,000">$125,000</option>
                               <option value="$150,000">$150,000</option>
                               <option value="$175,000">$175,000</option>
                               <option value="$200,000">$200,000</option>
                               <option value="Over $200,000">Over $200,000</option>
                           </select>

                       </div>
                   </div>

               </div>
               <div class="span5">
                   <div class="control-group">
                       <label style="padding-top: 0;" class="control-label">What is the monthly amount of your rent or mortgage?</label>

                       <div  class="controls">
                           <input class="span3" type="text" placeholder="Monthly amoun">
                       </div>
                   </div>
                   <div class="control-group">
                       <label class="control-label">Other income</label>

                       <div class="controls">
                           <input class="span3" type="text" placeholder="Other income">
                       </div>
                   </div>

                   <div class="control-group">
                       <label class="control-label">On a scale of 1-10, 1 being the lowest rating, how would you rate your own credit?</label>

                       <div class="controls">
                           <select style="margin-top: 24px;" name="form[CreditRating][]" id="CreditRating">
                               <option value="10">10</option>
                               <option value="9">9</option>
                               <option value="8">8</option>
                               <option value="7">7</option>
                               <option value="6">6</option>
                               <option value="5">5</option>
                               <option value="4">4</option>
                               <option value="3">3</option>
                               <option value="2">2</option>
                               <option value="1">1</option>
                           </select>

                       </div>
                   </div>
                   <div class="control-group">
                       <label class="control-label">What is the purpose of this loan?</label>

                       <div class="controls">
                           <select style="margin-top: 10px;" name="form[LoanPurpose][]" id="LoanPurpose" class="rsform-select-box">
                               <option selected="selected" value="">Please Select</option>
                               <option value="Personal Loan">Personal Loan</option>
                               <option value="Mortgage Loan">Mortgage Loan</option>
                               <option value="Business Loan">Business Loan</option>
                               <option value="Debt Consolidation Loan">Debt Consolidation Loan</option>
                               <option value="Refinance">Refinance</option>
                               <option value="Other">Other</option>
                           </select>
                       </div>
                   </div>
               </div>
            <div style="clear: both;"></div>
                <div class="form-actions">
                    <button type="submit" class="btn btn-primary">I agree, Submit</button>
                    <button type="reset" class="btn">Cancel</button>
              </div>
            </form>
        </div>

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            <h4>Good4tocuh.com</h4>
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